1. Introduction
Indigenous Australian communities struggle to avoid the impact of alcohol and other drug (AOD) misuse. Up to 37% of Indigenous people aged over 15 have engaged in binge drinking, and alcohol related disease accounts for the greatest proportion of the burden of disease for young men (Australian Bureau of Statistics (ABS), 2010). Rates of consumption and AOD-related harm among Indigenous Australians are generally twice those in the non-Indigenous population (Gray & Wilkes, Reference Gray and Wilkes2010). Whole families and communities are adversely affected by violence, antisocial behaviour, unemployment and adverse impacts on unborn children (fetal alcohol spectrum disorder – FASD) (Department of Aboriginal and Torres Strait Islander and Multicultural Affairs (DATSMA), 2010–2012; Gray & Wilkes, Reference Gray and Wilkes2010; National Indigenous Drug and Alcohol Committee, Reference Stokes2012).
One in five Indigenous Australians over 15 used an illicit substance in 2008/09 with marijuana the most commonly reported illicit drug (Australian Institute of Health and Welfare, 2010). Recent studies of communities in Arnhem Land (Northern Territory) and on Cape York (Far North Queensland) indicate that 60% or more of those surveyed used cannabis at least weekly (Bohanna & Clough, Reference Bohanna and Clough2011; Lee, Clough, & Conigrave, Reference Lee, Clough and Conigrave2007). In the Indigenous populations of Far North Queensland psychotic disorders including schizophrenia, mood disorders, acute and transient psychoses are increasing and are linked with substance misuse (Hunter et al., Reference Hunter, Gynther, Anderson, Onnis, Nelson, Hall and Groves2012).
Federally funded Indigenous specific AOD services report high numbers of presentations of people with a range of social and emotional wellbeing and health issues (Office of Aboriginal and Torres Strait Islander Health, 2009). The dominant eudaimonic Western tripartite model of emotional, psychological and social wellbeing, however, underlies mainstream studies of mental health and mental illness (Keyes, Reference Keyes2005; Keyes & Simoes, Reference Keyes and Simoes2012). The model has been shown to fall short when working to optimise the social, psychological and emotional health of Australian Aboriginal and Torres Strait Islander people. In the context of Australian Indigenous health, social and emotional wellbeing is a broad concept that recognises the importance of connection to land, culture, spirituality, ancestry, family and community, and how these affect the individual (Zubrick et al., Reference Zubrick, Dudgeon, Gee, Glaskin, Kelly, Paradies, Walker, Purdie, Dudgeon and Walker2010). The physical and mental health status and outcomes of a person's care depend upon them and a balance then is sought to meet basic needs (Haswell et al., Reference Haswell, Hunter, Wargent, Hall, O'Higgins and West2009). The distinction between mainstream and Indigenous meanings of mental health includes a broader understanding of social and emotional wellbeing:
‘Social and emotional well-being problems cover a broad range of problems that can result from unresolved grief and loss, trauma and abuse, domestic violence, removal from family, substance misuse, family breakdown, cultural dislocation, racism and discrimination, and social disadvantage. (Zubrick, et al., Reference Zubrick, Dudgeon, Gee, Glaskin, Kelly, Paradies, Walker, Purdie, Dudgeon and Walker2010)
There is an increasing coincidence of mental health disorders and illnesses associated with substance abuse (Hunter et al., Reference Hunter, Gynther, Anderson, Onnis, Nelson, Hall and Groves2012; Parker, Reference Parker, Purdie, Dudgeon and Walker2010). Researchers were commissioned by the executive management body of a newly established rehabilitation service to collate a selection of culturally appropriate and validated instruments for the assessment of social and emotional wellbeing. Thinking holistically about Indigenous health and evaluating residents’ changes in personal wellbeing within the context of their involvement within the residential setting was deemed by the service's managers and stakeholders to be an appropriate lens to measure the efficacy of treatment. The aim of this study was to compile a suite of reliable and validated instruments suitable for screening and assessment of co-morbidity risk at entry/during treatment, and changes in social and emotional wellbeing during treatment at the service.
2. Methods
2.1. Context
A therapeutic community (TC) model has been developed in far north Queensland; a welcome addition to existing service provisions in the region. Presently, community-based substance misuse services, located mainly in regional centres provide open access AOD-specific health promotion programmes, counselling and diversion programmes, pharmacotherapy and community and home-based detoxification. A culturally competent TC model is unique to the region (Stephens et al., Reference Stephens, Graham, Clough, Turnour, Bohanna, Selway and Tsey2012). Whilst the ‘evidence’ on the therapeutic community model lacks consensus, there is a sufficient knowledge-base to suggest that the model can provide a verifiable and effective treatment for some client groups (De Leon, Reference De Leon2010). The managers of the service are funded to provide equal and equitable access to psychosocial assessment and treatment, which includes therapeutic communities for those who would benefit (Campling, Reference Campling2001), and are committed to ongoing evaluation research to contribute to a broader understanding of the evidence-base for effective therapeutic community practice.
2.2. Search methods
The reference lists of two reviews of instruments that were developed for, and are widely used in Australian AOD settings, Deady (Reference Deady2009) and Dawe, Loxton, Hides, Kavanagh, & Mattick (Reference Dawe, Farnell and Harlen2010) (Figure 1a), were examined. Both studies reviewed instruments for use in AOD settings with Dawe et al. (Reference Dawe, Farnell and Harlen2010) using search terms to find instruments ‘developed for’ or ‘specifically adapted’ for use with Aboriginal and/or Torres Strait Islander people. The reference lists contained peer-reviewed instruments of potential value to the new service. Twenty-three instruments from these sources were included in the review. Databases were then searched to find recent items. Over 78,000 records were identified in MEDLINE; PsycINFO and the Cochrane Database of Systematic Reviews using the terms; ‘co-morbidity’ and ‘assessment’ with ‘alcohol’, ‘drug’ or ‘substance’. These results were screened for ‘wellbeing’ leaving 403 texts searched for their relevance to Aboriginal and Torres Strait Islander Australians using the terms ‘Indigenous’ or ‘Austral*’ ‘Aboriginal’ AND/OR ‘Torres Strait Island’ (see Figure 1b). After duplicates with records found in Deady (Reference Deady2009) or Dawe et al. (Reference Dawe, Farnell and Harlen2010), nine relevant instruments were included in the review. Eight websites were reviewed (Figure 1b); the National Drug and Alcohol Research Centre; Australian Indigenous Health Info Net; National Drug Research institute, the Close the Gap Clearinghouse, the National Clearinghouse for Alcohol and Drug Information, the Register of Australian Drug and Alcohol Research, the International Well-being Group (Deakin University) and the Positive Psychology Centre (Penn State University), and eight additional items were included in the review.
Selections from Deady (Reference Deady2009) and Dawe et al., (Reference Dawe, Farnell and Harlen2010)
Details of database literature review and website based search
2.3. Literature evaluation framework
Both screening and assessment instruments were included. Instruments with a demonstrated use in AOD settings that had been used and/or validated with Aboriginal and Torres Strait Islander Australian populations were included. Co-morbidity assessment instruments across mental health symptomology, general health and social functioning were included if they pertained to assessments of wellbeing. The method of administration of the instrument was highly significant to the end-users of these instruments, as the service's staff, in the main, were non-clinically trained. Therefore, brief instruments that do not require high levels of clinical practice training and skill were included whilst instruments with high costs associated with implementation/training were excluded.
3. Results
A total of 40 screening and/or assessment instruments were selected to assist non-clinical staff evaluate the wellbeing of their clients in terms of their AOD recovery and mental health, at entry/admission assessment and/or during treatment. They were organised into five categories based on the nature of the instrument as a measurement tool. These were:
a) General health and functioning instruments (4)
b) Mental health and mental illness screeners (8)
c) Specific psychopathology (6)
d) Positive mental health instruments (17)
e) General AOD Instruments (5)
The characteristics of each instrument were presented in a summary table for the commissioning agency (Tables 1a–e). Characteristics of the instruments are described in column headings, each reflecting a criterion. The five descriptive categories were:
1. Established psychometric utility and used in AOD treatment settings.
2. Developed for, used with, and/or validated specifically for Australian Indigenous populations.
3. Administered by self-report and/or interview.
4. Administration time < 20 minutes.
5. Freely accessible and in the public domain.
General health and functioning instruments - key characteristics
1Development of Indigenous specific versions of HoNOS being developed by the Townsville Institute of Mental Health Services and Mental Health Clinical Improvement Team.
2Development of Indigenous specific versions of LSP being developed by the Townsville Institute of Mental Health Services and Mental Health Clinical Improvement Team.
3Contact: The Australian Health Outcomes Collaboration (AHOC) c/- Centre for Health Service Development University of Wollongong, NSW.
Mental health and mental illness screeners
4Developed in Queensland, Australia, by Indigenous and non-Indigenous researchers.
5Developed in South Australia by Relationships Australia and South Australian Department of Health and Ageing.
Specific psychopathology instruments - key characteristics
Positive mental health instruments - key characteristics
6Developed with extensive consultation with Indigenous and non-indigenous mental health experts.
General AOD instruments - key characteristics
Instruments’ psychometric utility and use in AOD settings was a key concern to build a collection of relevant tools. The second characteristic focused the search on Australian Indigenous-specific instruments or mainstream instruments used with Indigenous cohorts, and was recorded in the table as ‘yes’, ‘no’ or ‘unknown’. A simple administration of self-report and/or interview was recorded, including the use of computer programmed versions, a symbol is provided for each of these. Flexibility in administration of the instruments was important to the commissioning agency, as AOD workers wanted a choice between interview, self-report and/or computerised versions to enable them to meet their clients’ varying literacy levels. It also mattered to case workers that instruments help facilitate dialogue and build rapport between the client and their case worker. The physical and emotional wellbeing of clients on the day may also influence the method by which the instrument is performed. The brevity of the instrument (less than 20 minutes for the purposes of this review) was a characteristic of interest as well as its licence/purchasing cost to the centre. A brief description of the instruments’ aim was included. This category distinguished between screening and assessment tools to provide guidance on the value of the instrument across the treatment spectrum. Some additional notes were included if they concerned any of the five criterion. The columns in Tables 1a–e are descriptive and do not rank or rate the instruments.
3.1. Overview of identified instruments
Tables 1a–e presents 40 instruments which include screening and assessment measurement instruments developed for mainstream or Indigenous-specific use. The instruments screen and assess for general health and wellbeing, specific drug and alcohol use and co-morbidity issues to generate a holistic view of a client's personal, social, emotion, spiritual and cultural wellbeing. Under ‘general health and functioning instruments’ (Table 1a) there are four instruments, two of which have been modified for Indigenous-specific practice, the Health of the Nation Outcome Scales (HoNOS) (Royal College of Psychiatrists, 2006) and the Life Skills Profile (LSP) (Rosen, Hadzi-Pavlovic, Parker, & Trauer, Reference Rosen, Hadzi-Pavlovic, Parker and Trauer2006). The ‘mental health and mental illness screeners’ (Table 1b) contains eight screening tools to identify co-morbidity issues. This category includes the Aboriginal Symptoms checklist – Youth (WASC-Y) (Westerman, Reference Westerman2003) for Aboriginal youth; and the Indigenous Risk Impact Screen (IRIS) (Schlesinger, Ober, McCarthy, Watson, & Seinen, Reference Schlesinger, Ober, McCarthy, Watson and Seinen2007) developed for Aboriginal and Torres Strait Islander adults. Six assessment instruments to reveal ‘specific psychopathology’ were collected (Table 1c) and 17 instruments were placed in the ‘positive mental health’ range (Table 1d), which include several Indigenous-specific assessments, which will be discussed further below. The final category (Table 1e) contains five general AOD instruments (screeners and assessment instruments) that have widespread applicability to the AOD treatment sector, some with evidence of use with Indigenous cohorts. These include the Addiction Severity Index (ASI) (McLellan et al., Reference McLellan, Kushner, Metzger, Peters, Smith, Grissom and Argeriou1992); Australian Alcohol Treatment Outcome Measure (AATOM-C) (Melanie Simpson, Jan Copeland, & Peter Lawrinson, 2008; M. Simpson, J. Copeland, & P. Lawrinson, 2008); Alcohol Use Disorders Identification Test (AUDIT) (Babor, Higgins-Biddle, Saunders, & Monteiro, Reference Babor, Higgins-Biddle, Saunders and Monteiro2001); The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (WHO ASSIST Working Group, 2002); and the Severity of Dependence Scale (SDS) (Gossop et al., Reference Gossop, Darke, Griffiths, Hando, Powis, Hall and Strang1995). Several screening instruments may also be used in multiple time point analyses of client wellbeing gains.
3.2. Characteristics of identified instruments
Established psychometric utility/measure and used in AOD treatment settings
This category recorded validated instruments that may or may not have been validated within AOD treatment settings. Twenty-six of these instruments have documented evidence of use with AOD clients. There are eight instances where published evidence to this affect was not found therefore a symbol representing ‘unknown’ was recorded and eight of these were found to be positive mental health instruments. This does not preclude the likelihood of instruments such as the ASSIST and the AUDIT, being used prior to formal treatment intervention.
Developed for, used with and/or validated specifically for Indigenous populations
This category captured documented evidence of instruments, within this collection, being used within Indigenous populations; developed for, and/or validated with Indigenous populations. Tables 1a–e shows evidence of use for 18 of the 40 instruments. Seven instruments were developed and validated specifically for Aboriginal and/or Torres Strait Islander clients. Most of these are to assess Indigenous conceptions of mental health and emotional wellbeing. They included the IRIS; Aboriginal Symptoms checklist – Youth (WASC-Y); Aboriginal Mental Health Cultural Competency Test (CCT) (Westerman, Reference Westerman2012) (these have not been validated with Torres Strait Islander people); the Growth and Empowerment Measure (GEM) (Haswell et al., Reference Haswell, Kavanagh, Tsey, Reilly, Cadet-James, Laliberte and Doran2010); and Strong Souls (Thomas, Cairney, Gunthorpe, Paradies, & Sayers, Reference Thomas, Cairney, Gunthorpe, Paradies and Sayers2010). There are modified versions of majority culture tools; the HoNOS (Pedro & Dillon, n.d.), CogState (Cairney, Clough, Jaragba, & Maruff, Reference Cairney, Clough, Jaragba and Maruff2007); Life Skills Profile (Pedro & Dillon, n.d.), PHQ-9 (Esler, Johnston, Thomas, & Davis, Reference Esler, Johnston, Thomas and Davis2008) and the Personal Well-being Index (International Wellbeing Group, 2006). Only one Indigenous-specific instrument, the GEM, has been the subject of study in a NSW residential treatment service (Berry, Crowe, Deane, Billingham, & Bhagerutty, Reference Berry, Crowe, Deane, Billingham and Bhagerutty2012). The AUDIT and the ASSIST have both been widely validated among several culturally diverse populations (Dawe, Farnell, & Harlen, Reference Dawe, Farnell and Harlen2010; Deady, Reference Deady2009) and the AUDIT is recommended for use with Indigenous Australians in AOD settings (Dawe et al., Reference Dawe, Farnell and Harlen2010).
Administered by self-report/interview or other
Ten instruments specified interviews, seven specified an either/or approach and 21 were self-report. Five instruments, the SF-36® Health Survey, the CCT, CogState, the Quality of Life Inventory (QOLI) (Frisch, Cornell, Villanueva, & Retzlaff, Reference Frisch, Cornell, Villanueva and Retzlaff1992) and the AUDIT, have been developed or adapted to be administered by computer. Flexibility of approach gives greater choice to the AOD workers.
Administration time
The brevity of administration was recorded. Brevity is defined as requiring less than 20 minutes to complete. The Addiction Severity Index (ASI), the WASC-Y, and the Silver Lining Questionnaire (SLQ) (McBride, Dunwoody, Lowe-Strong, & Kennedy, Reference McBride, Dunwoody, Lowe-Strong and Kennedy2008) may all take longer than 20 minutes. All other instruments should take < 20 minutes to administer.
Accessibility
Tables 1a–e show that 32 of the total sample of instruments are in the public domain. This was important to the service which has limited available funding for licences of instruments. The SF-36® Health Survey, the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, Reference Beck, Ward, Mendelson, Mock and Erbaugh1961), the Depression Anxiety Stress Scale (DASS) (Psychology Foundation of Australia, 2011), WASC-Y, CCT, CogState and the Ryff Scales (Springer & Hauser, Reference Springer and Hauser2003) have varying costs associated with licensing of use and/or specific training/course requirements. This does not negate all costs associated with training and the use of the instruments, but these may be reasonably absorbed by the centre's programme and staff training operating budget.
4. Discussion
The suite of instruments represented in Tables 1a–e have desirable characteristics for use in the Indigenous-specific therapeutic community. The suite is also required to meet multiple objectives in terms of the needs of the service.
A priority concern was to collect instruments that screen for or assess an aspect of social, emotional or physical wellbeing. However, the important differences between the concept of mental health in Australian Indigenous culture and eudaimonic traditions that may result in a range of instruments being available to staff that do not promote cultural competency as they are lacking in the appropriate cultural adaptations for secure cultural practice in an Australian health setting. Cultural competency is knowledge, awareness and skills that promote and advance cultural diversity and the recognition of the uniqueness of self and others in communities (Walker & Sonn, Reference Walker, Sonn and Purdie2010). Western psychological concepts, such as individualism embedded within mainstream instruments, may limit the appropriateness of a tool (Kowal, Gunthorpe, & Bailie, Reference Kowal, Gunthorpe and Bailie2007). For this reason a wide range of instruments were collected from the positive mental health tradition. The strengths-based and hedonic positive psychology movement directs researchers and practitioners to focus on positive perceptions of individuals through an understanding of positive emotions, positive individual traits, and positive institutions (Positive Psychology Center, 2007). The strengths-based approach is consistent with the therapeutic community model being established at the treatment facility and is more consistent with the Aboriginal and Torres Strait Islander conception of social and emotional wellbeing that takes a holistic approach where culture, historicity, social structures and ties are accounted for within the instrument. Half of the Indigenous-specific instruments found were categorised as positive health instruments (see Table 1d). The WASC-Y, CCT, modified CogState, the GEM, Personal Well-being Index, and Strong Souls Inventory assess cognition, satisfaction, empowerment and cultural awareness using a holistic, strengths-based approach.
The majority of instruments have documented use in AOD settings. Instruments with unknown documentation regarding their application in AOD treatment were many times found to be recommended for use and rated well on other descriptive criteria. Instruments that have a brief and flexible method of administration, are low cost or freely available in the public domain and require minimal levels of clinical skill were included. It is a requirement for both staff and clients that the instruments selected offer simple but effective methods of data collection. The AOD workers are, in the main, non-clinically trained and clients may have varying levels of literacy. Instruments that encourage and build rapport and promote dialogue between the client and worker have been deemed desirable by the staff. The service also required a selection of instruments that enable them to screen for co-morbidity issues to inform case management decisions in terms of external professional care and use of auxiliary services to the centre.
Measuring wellbeing through a range of social and clinical constructs broadens the range of individual-level outcomes and service-level processes that equate to good quality care. Several of the instruments have implications for the whole-of-service programme evaluation and evidence of service outcomes. Service accreditation frameworks, such as the recently launched Standard on Culturally Secure Practice (Alcohol and other Drug Sector) expect service providers to plan the service and individualised client care in accordance with evidence based practice (Western Australian Network of Alcohol and Drug Agencies (WANADA), August, 2012).
A competing request by staff concerns the detrimental impact on their clients if multiple sets of instruments are employed with high frequency. It would be preferable to substitute one culturally-appropriate instrument for many. The GEM has been validated for use in AOD settings and was developed by and for Indigenous Australians to measure wellbeing changes over time (Berry et al., Reference Berry, Crowe, Deane, Billingham and Bhagerutty2012). Its use may minimise the assessment burden upon both AOD workers and clients, albeit the administration time does not meet this review's definition of ‘brief’. Nevertheless, the GEM is now being administered at three time-points during the course of a client's 6–9 month stay at the service.
The review highlights the urgent need for a wider selection of validated instruments for Indigenous populations. The review found few examples of instruments that have been specifically developed or validated for use with Indigenous populations and even fewer validated for use in AOD treatment settings. The current lack of validated or appropriately adapted instruments limits the capacity for gathering evidence about best practice clinical care, potentially constraining practice and placing an individual's health and wellbeing at risk. This is an ongoing project for researchers and health sector staff requiring both time and funding, however in the short term, where appropriate, instruments may be adapted or modified to better tailor assessments to Indigenous clients’ needs to provide culturally relevant health care (Wilkes, Gray, Saggers, Casey, & Stearne, Reference Wilkes, Gray, Saggers, Casey, Stearne, Purdie, Dudgeon and Walker2010; Wilson & Baker, Reference Wilson and Baker2012). Where possible the developers of the instrument and key stakeholders should be involved in the modification process (Burgess, Pirkis, Coombs, & Rosen, Reference Burgess, Pirkis, Coombs and Rosen2011). A staff training and implementation strategy has been undertaken at the centre with external consultants, researchers and, where possible, developers of the tools. Furthermore a process of review, consultation, implementation and ongoing quality control to modify and tailor screening and assessment instruments on a continuous improvement basis is in development with service staff.
5. Conclusion
The study collated a suite of instruments that can be used in the assessment of Indigenous social and emotional wellbeing in a residential AOD treatment setting. Several instruments were found to be designed specifically to measure Indigenous notions of social and emotional wellbeing. Mainstream instruments have potential and relevance, but may require appropriate adaptation with the service prepared to absorb the costs associated with those processes. Modifications must be undertaken with care to involve AOD workers and clinical supervising staff in the processes, and may be regarded as a step towards the design of a culturally competent health service.
Given the level of harm caused by substance misuse in Indigenous communities’ however, poor quality evidence is unacceptable and research for validation and sensitivity assessments of instruments acceptable for use with Indigenous Australians in AOD treatment, is urgently required.
